Dr. Jeffrey Tucker Presents The Program For Total Health.

Dr. Jeffrey TuckerPresents

The Program For Total Health

The gold standard is health span

Of American women ages 45 – 54• 33% suffer from hypertension• 32% have lower back pain• 20% have elevated blood pressure• 22% have knee pain• 21% have neck pain• 12% have shoulder pain• 11% have finger pain

The gold standard is health span

Of American men ages 45 – 54:• 30% suffer from hypertension• 27% have lower back pain• 20% have elevated blood pressure• 19% have knee pain• 15% have neck pain• 13% have shoulder pain• 7% have finger pain

• American diet: about 72% of the calories in the average American's diet come from foods that were not consumed by our recent hunter-gatherer ancestors. Consider that 23% come from grains (20.4% from refined grains), 18.6% from refined sugars, 17.6% from refined omega-6 seed oils (corn, soybean, sunflower, cottonseed, safflower, peanut, etc.), 10.6% from dairy, and about 1.4% from alcohol. 

• Cordain L, Eaton SB, Sebastian A, et al. Origins and evolution of the Western diet: health implications for the 21st century. Am J Clin Nutr, 2005;81(2):341-54.

• The remaining 28% come from a marginal intake of fruits, vegetables, nuts and legumes, and a substantial intake of domestic, feedlot, grain-fed meat. We know wild game is about 2% to 4% fat by weight, while modern feed-lot meat is 20% to 24% fat by weight. Essentially, this means we are eating unhealthy, obese animals.

• Seaman DR. The diet-induced pro-inflammatory state: a couse of chronic pain and other degenerative diseases. J Manip Physiol Ther, 2002;25:168-79.

• In short, our diet in America today consists of grains, sugars, omega-6 fatty acids, trans fats, and obese meat, and is substantially deficient in fruits and vegetables. The outcome of this pattern of eating is the typical inflamed, swollen-looking, overweight American, who is prone to osteoporosis, osteoarthritis, chronic pain, and other chronic diseases.

•

Dr. Tucker’s Therapeutic Lifestyle Program

• Diet

• Exercise

• Supplement

• Rest

The Program Will Address

• Making healthy food choices• Preventing chronic disease formation• Improving body composition• Reducing body fat storage• Increasing lean muscle mass• Reducing inflammation• Improving blood sugar management • Reducing hyperinsulinemia and hyperglycemia• Increasing exercise & physical activity = gentle

movement therapy & strength training

Charting Office VisitsSOAP Note Format

• Subjective

• Objective

• Assessment/Diagnosis

• Functional abnormalities

• Plan (diet modifications, exercise program, supplementation recommendations, relaxation techniques)

Office Flow Algorithm

1. The doctor prescribes the program to the patient

2. Patient assessment (BIA, blood, FMS)3. Patient consultation (ROF, establish

goals, individualize the program)4. Follow up visits5. RetestBIA = Bioelectrical impedance analysisFMS = Functional Movement ScreenROF = report of findings

Retest

• Program goals are achieved

• Prescribe maintenance program

• Send re-evaluation reminder card in 6-12 months

• Program goals are not achieved

• Return to step 3 previous slide

Timing of Return Visits Recommended Follow Up

• Medical Doctor (weeks)1. Forms/Assessment (blood, etc.)2. Consultation/Refer to Tucker for

Total Health program3. Tucker4. Tucker/Follow up visit MD5. Tucker6. Tucker7. Tucker8. Tucker/MD9. Tucker10. Tucker11. Tucker12. Re-evaluation MD

• Tucker (weeks)1. Forms/Assessment/BIA2. Diet/meal plan/supplements3. Functional Movement Screen4. Education/exercise5. Education/exercise/BIA6. Education/exercise7. Exercise8. Exercsie9. Retest FMS/BIA10.Exercise11.Retest FMS/BIA12.Re-evaluate Tucker/MDFMS = Functional Movement ScreenBIA = Bioimpedance Analysis

Charging for Programs

• Determine what method of payment will work best for patients.

• Determine cost of services.

• Supplements are charged for separately.

Counseling For Patients With NO Medical Illness or Symptoms

Insurance codes:

• 99401 15 Minutes

• 99402 30 Minutes

• 99403 45 Minutes

• 99404 60 Minutes

• Patients can call there own insurance company and ask them how much they will reimburse for these services.

Individual and Group Counseling WITH Medical Illness or Symptoms• For counseling GROUPS of patients 99078• For counseling INDIVIDUALS• 99213 Consultation 15 min ____• 99214 25 min ____• 99215 40 min ____• 99244 60 min ____ • 99245 90 min ____ • 99354 Prolonged Care $150

Bioimpedance Analysis (BIA)

• A4556 BIA Electrodes (2 sets @ 15 each)

• $30

• Provides: Body composition, fluid distribution, phase angle

• This test can be performed as often as necessary to document changes in body fat and lean muscle mass.

BIA may be used

To assess:

- Body composition (estimate)

- Fluid balance

- Cellular performance (cellular health analysis)

Body composition - BCM

• Loss of BCM (sarcopenia) is associated with a reduced quality of life, poor immune response, increased biological age, osteoporosis, and impaired healing.

Body Composition - BCM

• It takes three times longer to accumulate BCM as to deplete it.

• To increase BCM you must remove catabolic factors (stress, anxiety, sedentary behaviors, insulin resistance, etc.), increase protein calories, and introduce resistance training.

Trunkal Obesity/Central Adiposity

• Waist Circumference

• Waist to Hip Ratio

Vital Signs

• BP

• Pulse

• Temp

Hypertension Staging

• Pre-hypertension– Systolic BP: 120-139 mm Hg; diastolic BP: 80-89 mm

Hg

• Stage I– Systolic BP: 140-159 mm HG; diastolic BP: 90-99 mm

Hg

• Stage II– Systolic BP: 160-179 mm HG; diastolic BP: 100-109

mm Hg

• Stage III– Systolic BP: 180+ mm HG; diastolic BP: 110+ mm Hg

Hypertension• Stress – Adrenal hyper/hypo function

i.e: addison/cushings or other adrenal tumor. Test with urine cortisol or 24 hour urine test for vanillylmandelic acid and catecholamines (severe HTN)

• Renal function (U/A)• Congestive heart failure/atherosclerosis• Hyperinsulinemia• Hypothyroid• Lymphatic congestion• Drug interaction/reaction

– Especially contraceptive pills, steroids, decongestants, appetite suppressants

• Lifestyle– Alcohol, obesity, smoking, high sodium, lead toxicity (soft water),

caffeine

Lab: Cardiovascular

• Lipids, fractionated lipid profile

• Hs-CRP

• Fibrinogen

• Homocysteine

Highly Sensitive C-reactive Protein

• C-reactive protein – is an important independent marker for inflammation.

• High levels reflect over activity of inflammatory cytokines linked to coagulation and vascular endothelium damage.

• Evidence suggests that previous infection with pathogens such as Chlamydia pneumoniae or Helicobactor pylori may act as an initiating trigger for this chronic inflammation.

C-Reactive Protein

• Marker of inflammation, infection and cell injury– Aspirin’s reduction of MI risk appears to be related to

CRP levels– CRP activates complement which injures the inner

layer of blood vessels leading to constriction of vessels, arrhythmia

• Strong predictor of the risk of future MI– Study of 2,037 healthy middle-aged men from the

Quebec Cardiovascular Study:– 105 first cardiac events during 5 years of follow-up

lead to 1.8 fold increased risk of ischemic heart disease when CRP was at least 1.77 mg/L

hs-CRP

• Is helpful in assessing risk for unstable plaque, myocardial infarction, and diabetes.

• Elevated levels of CRP and IL-6 predict the development of type 2 DM. these data support a possible role for inflamation in diabetogenesis.

• JAMA, 2001, Vol 286: 327-334

Diseases Associated With Defective Methylation Capacity

• Atheroscelosis, coronary artery disease, deep vein thrombosis, stroke

• Neural tube defects, spontaneous abortion, placental abruption

• Cervical dysplasia, cervical cancer• Colon cancer• Cognitive impairment, depression, senility,

Alzheimer’s disease• Osteoporosis, RA, diabetes

MTHFRMethylenetetrahydrofolate reductase

• MTHFR is involved in the conversion of homocysteine to methionine via the remethylation pathway

• Polymorphism associated with increased levels of homocysteine and defective methylation

MTHFR – Intervention

• Folic acid/5-MTHFR

• Vitamin B12/Methylcobalamin

• Vitamin B6

• Roboflavin: precursor for FMN (flavin mononucleotide) (B6 to p-5-p), precursor for FADH2 (flavin dinuceotide), coenzyme for MTHFR

• Betaine/TMG

Fibrinogen

• Plays a key role in arterial occlusion by promoting thrombus formation, endothelial injury, and hyperviscosity.

• Increased fibrinogen levels are seen with: smoking, oral contraceptive use, obesity, stress, inflammation, insulin resistance, and aging.

• Higher risk: elevated fibrinogen with high total cholesterol or elevated LDL; elevated fibrinogen with high CRP.

Lab: Metabolic Syndrome/DMII

• Glucose-fasting and two hour

• Insulin-fasting and two hour

• HgbA1C

Lab: Altered Endocrinology

• Adrenal Stress Profile – salivary cortisol

• Thyroid

Lab: Objective Goals

• Total cholesterol – under 200• Triglyerides – under 150• HDL – over 50 (male) and over 60 (female)• LDL – under 130 (under 100 if blood risks are

present)• Trig/HDL ratio – under 3.0Adults 3+ screen for IR

Children 2+ screen for IR

• LipoproteinsA1 and B

American Cholesterol education program expert panel’s current policy on fasting blood triglyceride levels in adults:

Less than 150 mg/dl (<1.7 mmol/L)

Normal

150 -199 mg/dl (1.7-2.3 mmol/L)

Boderline-high

200 – 499 mg/dl (2.3-5.64 mmol/L)

High

Higher than 500 mg/dl (>5.64 mmol/L)

Very high

How to Make the Program Flow

• Where I begin with a new patient:– Initial consultation– Charting the Subjective Intake– Establishing the patient’s health goals to start

their Lifestyle Change Program– Objective findings: ordering or collecting data– Review of findings (first or second visit)– Developing their unique program– Follow up appointments

Complete the Health Profile Questionnaire (HPQ)

• Anyone scoring over 50 points total or 10 or more in any one section would benefit from a detoxification program.

• Even individuals scoring as low as 25-30 will experience greater energy, clarity, vitality and find that nagging symptoms of unknown origin often get better.

• Go to www.DrJeffreyTucker.com to complete this form.

The Initial Health Consultation

• Subjective interview– HCP Prescription– Health History– Health Profile Questionnaire (HPQ)– Diet/Exercise/Sleep/Stress Diary– Client’s Health Goals– Assessing Readiness to Change

The Initial Health Consultation

• Objective Data Collection– BIA and vitals

• Review of Findings

• Begin Education and Health Coaching

Lifestyle Change – How?

• It takes 45 days to change a habit or incorporate a new one.

Diet Diary/Exercise log

• Are you filling yours out daily?• Keep track of:

– Everything you eat– Everything you drink– Your Activity/Exercise

• People who self-monitor both eating and exercise behaviors, are more successful at reaching and maintaining their ideal weight.

• The American College of Sports Medicine. (Med Sci Sports Exerc 2001 Dec;33(12):2145-56)

Portion sizes & eating frequency• Don’t skip meals- Skipping meals leads to increased production of

glucagon & gluconeogenesis resulting in muscle loss• Eat frequently- 3 small meals and 2-3 snacks daily- To maintain stable blood sugar and insulin levels- Use high quality meal replacement to: Achieve frequency goals Increase nutrient intake while decreasing calorie intakeDo the body composition analysis to find out your body fat

percent and lean muscle mass.

Identifying the clients that will benefit from this program:

• Altered Body Composition– Sacropenic obesity– Weakness and Fatigue

• Inflammatory Conditions• Abnormal Blood Sugar Regulation

– Insulin Resistance/Hyperinsulinemia– Metabolic Syndrome– Type II Diabetes

• Cardiovascular Risks– Hypertension– Hyperlipidemia

Inflammatory Related Chronic Disorders

• Obesity (Adipocyte)

• Sarcopenia (Muscular)

• Atherosclerosis (Cardiovascular)

• Type II Diabetes (Endocrine)

• Osteo- and Rheumatoid Arthritis (Skeletal)

• Inflammatory Bowel Disease (Gastrointestinal)

Lifestyle Modifications and Preventing Disease

• 3,234 non-diabetic subjects with elevated fasting and post-load plasma glucose concentrations were randomized to placebo, Metformin (850 mg twice daily), or lifestyle-modification program. Program goals of at least a 7 percent weight loss and at least 150 minutes of physical activity per week. Initial average BMI = 34.

• At average follow up of 2.8 years, the lifestyle intervention reduced the incidence of progression to diabetes by 58 percent vs. the Metformin reduction of 31 percent (as compared with placebo).

• Knowler, W.C. et al., Reduction in the incidence of Type 2 Diabetes with lifestyle intervention or Metformin. N Engl

J Med. 2002. 346(6): p. 393-403

The goals of the diet are

• Decrease insulin stimulation via dietary changes which decrease insulin release

- ‘Good’ (vs ‘bad’) carbohydrates- Fiber- Moderate protein- ‘Good’ (vs ‘bad’) fat- Portion size & meal frequency• Increase cellular responsiveness to insulin:Chromium Green tea Lipoic acid CinnamonMagnesium

Definition of Glycemic Index

• Glycemic Index (GI) is defined as the incremental area under the blood glucose curve in response to a standardized carbohydrate load. It is therefore an index of the blood glucose raising potential of the available carbohydrate in a food.

Obesity as an Inflammatory Disorder

• Obesity reduces a lifespan by 8 to 20 years.

• One of the most interesting discoveries of the past decade has been the recognition that the adipocytes produces inflammatory cytokines.

• Obesity, therefore, may be viewed as a low grade systemic inflammatory disease.

What does the Adipocyte secrete?

• Resistin is an adipose tissue-specific factor inducing insulin resistance linking DM to obesity.

• Adiponectin is an anti-inflammatory, insulin sensitizing adipocytokine.

• Adiposity is a form of chronic, low-grade inflammation.

Mid-line trunkal obesity (VAT deposition)

• Cushingoid appearance –increased deposition in the visceral adipose tissue enhanced by increased levels of Insulin Glucocorticoids (cortisol)

• VAT contributes to: - Production of the release of TNFa, IL-1, IL-6 - Altered insulin sensitivity and glucose

tolerance -Thyroid hormone activity alterations

LIPOPSUCTION

The New England Journal of Medicine June 17, 2004

Liposuction (avg of 20 lbs) did not significantly alter the insulin sensitivity of muscle, liver, or adipose tissue; did not significantly alter plasma concentrations of CRP, IL-6, TNFa, and adiponectin; and did not significantly affect other risk factors for coronary heart disease.

General Features of Metabolic Syndrome

• Abdominal obesityo Men – waist > 40 inches, or waist is larger than hipso Women – waist > 35 inches, or waist is greater than 80% the size of

hips• Altered blood lipids (fats)o High triglycerides , trig/HDL ratioo Small LDL cholesterol particleso Low HDL cholesterol• Raised blood pressure• Insulin resistance (+ glucose intolerance) • Pro-thrombotic state (blood clotting tendency)- Increased fibrinogen and PAI-1• Pro-inflammatory state- Increased IL-6 and hs-CRP

Clinical Identification of the Metabolic Syndrome

Risk Factor

Abdominal obesity

Men

Women

Triglycerides

HDL cholesterol

Men

Women

Blood pressure

Fasting glucose

Adult Dx: 277.7

Adult Dx 277.7

Defining Level

Waist Circumference

>102 cm (>40 in)

>88 cm (>35 in)

>150 mg/dl

<40 mg/dl

<50 mg/dl

>130/>85 mmHg

>100

NCEP ATP III

Metabolic Syndrome Patients

• Increased blood fat

• Increased body fat

• Increased muscle fat

• Increased liver fat

• Increased pancreatic fat

Do you know someone at risk?

• Approximately 90 million Americans have insulin resistance.

• 18.2 million Americans have diabetes.

• Over 5 million undiagnosed diabetes.

• Average time from onset to diagnosis is 4 to 7 years due to insidious nature in early stages.

• National Institutes of Health and Centers for Disease Control and Prevention

Insulin Resistance SyndromeMetabolic Syndrome

• Overweight or a waist circum.>40 inches for men, >35 inches for women.

• Elevated BP, blood glucose, blood lipids (triglycerides).

• Sedentary lifestyle.• Family history of type 2 diabetes, hypertension

or cardiovascular disease.• A history of glucose intolerance or gestation

diabetes.• Polycystic ovary syndrome.• Sleep apnea.

Almost half of severely obese children have metabolic syndrome

• “The overall prevalence of the metabolic syndrome was…

49.7 percent in severely obese subjects”

• N Engl J Med 2004;350:2362-74

Conditions related to insulin resistance (program candidates)

• Cardiovascular disease• Type 2 diabetes• Hypertension• Hyperlipidemia• Polycystic Ovary Syndrome• Overweight/Obesity• Cancer (colon, breast, prostate)• Sarcopenia• Accelerated aging• Sleep apnea• Alzheimers disease

Inflammatory Cytokines, Hyper-insulinemia, and Atherosclerosis

• A number of studies have domonstarted that increases in inflammatory mediators like IL-6 and hs-CRP are associated with insulin resistance and metabolic syndrome.

• Metabolic syndrome is strongly associated with the onset of endothelial dysfunction, which may explain why type-2 diabetes is a risk factor for atherosclerosis.

American College of Cardiology53rd Scientific Sessions - March 9, 2004

• National clinical guidelines recommend therapeutic lifestyle changes (TLC) as a standard of care in the management of CVD risk factors.

• The value of TLC in actual practice is often discounted by clinicians and health insurers who instead frequently turn to widely available pharmacotherapeutic agents.

• Emory University Health Sciences Center

American College of Cardiology53rd Scientific Sessions - March 9, 2004

• “Many patients with classic cardiovascular disease risk factors can achieve risk reduction goals without medications within only three months of initiating therapeutic lifestyle changes (TLC).”

• Emory University Health Sciences Center

Weight loss does not always lead to better health

• “Weight and BMI do not evaluate body compartments and therefore do not reveal if weight changes result in loss of fat-free mass or gain in fat mass.”

• J Amer Diet Assoc 2002;102(7):944-955

• BIA is a reliable resource for assessing body composition and tissue differentiation.

Why body composition and BMI are associated with increased risks

• Muscle mass is the #1 Bio-Marker of aging• Hence, the higher the muscle mass the greater

the longevity• Important for preventingSarcopeniaObesityHeart diseaseType II diabetesOsteoporosis

Body Mass Index

• Commonly used index of body composition

• Not useful for measuring percentage of body fat or lean body mass

• Patients with normal BMI may have sarcopenia or sarcopenic obesity

One in every six of your patient’s children are now obese

• The American Obesity Association uses a reference point of -85th percentile of BMI as overweight

• -95th percentile for obesity

• The American Obesity Association estimates that over 30% of America’s children can be classified as “overweight”

• US Department of Health and Human Services

Developmental Origins of Health and Disease

• As compared with members of the cohort in whom heart disease outcomes did not develop, those who were hospitalized for or died from coronary heart had relatively small body size during the first two years of life, then grew more rapidly through 11 years of age.

• Developmental Origins of Health and Disease, N Engl J Med;2005:353(17):1848

Trajectories of Growth Among Children Who Have Coronary Events as Adults

• On average, adults who had a coronary event had been small at birth and thin at two years of age and thereafter put on weight rapidly. This pattern of growth during childhood was associated with insulin resistance in later life. The risk of coronary events was more strongly related to the tempo of childhood gain in BMI than to the BMI attained at any particular age.

• New England Journal of Medicine

Clinical Importance of Obesity Versus the Metabolic Syndrome in Cardiovascular Risk in Women

A Report From the Women’s Ischemia Syndrome Evaluation

• The metabolic syndrome but not BMI predicts future cardiovascular risks in women.

• The prevalence exceeds 20% on individuals > 20 years of age and 40% of the population > 40 years of age.

Waist Circumference Predicts Metabolic Risk

• Men with a waist circumference greater than 40” and woman with a waist circumference greater than 35” are at increased risk for metabolic diseases.

• Klein S. The case of visceral fat: argument for the defense. J Clin. Invest. 2004; 113 (11): 1530-1532.

Obesity & Cancer

• 14% of obese patients will go on to have cancer.

• In 2020 1 in 26 people will get cancer.

• 5lbs of body fat looks like a loaf of bread.

Essential Fatty Acids (EFA’s)

• …are called essential because we MUST ingest them.

• Basically two types:

1. Omega-3’s found in cold water fish, nuts, canola oil and flaxseed.

2. Omega-6’s found in meat, cheese, nuts, seeds, grains, leafy vegetables, corn, safflower & soybean oil.

Clinical importance of EFAs

• Structural: all animals’ cell membranes.• -membrane stability.• -membrane fluidity.• -membrane-bound enzyme activities.• -receptor action.• -Permeability.• -ion-channel modulation.• Eicosanoid formation.• Cholesterol transport and oxidation.• Regulation of gene expression: FAs ‘talk to our genes.”

Classification of Fatty Acids

• Saturated (SFA)

• Monounsaturated (MUFA)

• Polyunsaturated (PUFA)

• Highly unsaturated fatty acids (HUFAs)

• Trans fatty acids (TFAs)

Classification of Fatty Acids

• Essential

-Linoleic acid (LA; omega 6)

-Alpha-linoleic acid (ALA; omega 3)

• Non-essential

-SFA, MUFAs, TFAs, few PUFAs.

What do EFA’s do?

• Modulate the inflammatory responses.• Dilate or constrict blood vessels, stomach,

intestines, bronchial tree, uterus.• Components of cell membranes:• -involved in cell-to-cell communication• -keep cell walls rigid or fluid• -control the flow of nutrients in & out of cells• Required for the production of RBC’s

Suggested therapeutic effects of EFAs

• Modulate autoimmune conditions.• Improve insulin resistance.• Improve lipids.• Reduce CAD.• Reduce arrhythmia.• CNS: depression, vision, possibly ADHD.• Cancer-prevention, metastases control,

and adjunct to RX.

Signs of EFA deficiency…

• All patients on the Standard American Diet

• Dermatitis – dry, scaly skin, follicullar hyperkeratosis

• Dry hair, dandruff• Brittle nails• Decreased memory

and mental abilities

• Psychological disturbances

• Impaired or increased immune responses

• Neuropathy• Reduced visual acuity• Increased

cholesterol/HDL ratio

Likely markers of EPA deficiency

• CVD• Arthritis• Syndrome X and

Insulin resistance• Inflammatory bowel

disease

• Irritable Bowel Disease

• Diabetes• Cancer• Skin diseases• Autoimmune disease

In general omega – 6’s…

• Are derived from linoleic acid and produce inflammatory prostaglandins that are associated with heart disease, cancer and other inflammation associated diseases.

-Enhance growth of precancerous cells-Initiate tumor growth-Increases rates of tumor growth-Promotes metastasis via PGE2 promotion-PGE1 from DGLA is protective

In general omega-3’s

• Are derived from alpha-linolenic acid and are associated with anti-inflammatory properties.

-Smooth muscle relaxation (lower BP).-Relaxation of intestines (enhances nutrient

absorption).-Enhanced ability for hormones to communicate

with target cells, decreasing the need for total hormone.

-Enhanced cell-to-cell communication (decreases rate o cell growth).

Dietary sources of EFAs• FoodOmega-3 (grams per 100g) • Flax 20.3• Hemp seeds 7.0 • Pumpkin seeds 3.2 • Salmon 3.2• Walnuts 3.0• Rape seed 2.1• Herring 2.0• Soybeans 1.2 • Butter 1.2 • Olive oil 0.6 • Wheat germ 0.5• Sunflower seeds 0 • Almond 0 • Olives 0

• Omega-6 (grams per 100g)• 4.9• 21.0• 23.4• 0.7• 30.6• 9.0• 0.4 • 8.6 • 1.8• 7.9 • 5.5• 30.7• 9.2• 1.6

Other References• Metabolism 1998;47:106-112 • Br J Nutr 2000;83:S59-S66 • Annu Rev Nutr 1999;19:63-90 • J Biol Chem 2000;275:30749-30752 • J Nutr 1998;128:923-926 • Am J Clin Nutr 1999;70:566-571 • Biochimie 1998;79:95-99 • Int J Obes 1997;21:637-643 • J Nutr 1997;127:2142-2150 • Am J Clin Nutr 1999;69:890-897 • Am J Clin Nutr 1999;70:817-825 • J Nutr 1990;120:544-552 • J Biol Chem 1998;278:5678-5684 • J Biol Chem 1999;274:23577-23583 • J Biol Chem 1999;274:471-477 • J Biol Chem 1999;274:37335-37339 • J Biol Chem 2000;275:32379-32282 • Natl Acad Sci USA 1999;96:1041-1048 • Scand J Med Sci Sports, 7(1): 25-31, 1997 • Eur J Appl Physiol, 87(3): 193-201, 2002 • J Appl Physiol, 80(2): 464-71, 1997 • J Nutr, 127(9): 1752-7, 1997 • Am J Clin Nutr: 1991, 54:438-463 • Food Standards Agency ‘Manual of Nutrition’ 10th edition

Omega-3 & Healthy Cardiovascular Function

• Omega 3 EFAs from fish support short- term as well as long-term cardiovascular health.

• “Our findings contradict the current belief in the medical community that increasing the intake of omega-3 fatty acids produces only long term cardiac benefits.” – Dr. Fernando Holguin

• Chest 127/4/April 2005

Omega-3s reduce the risk of heart attacks by up to 90%

• Siscovich et al. JAMA. 1995;274:1363-1367

Omega-3 and healthy body composition

• Fish oil concentrates not only caused weight reduction in the mice but also appeared to stop the animals from gaining weight when given free access to food.

• Additionally, omega-3 concentrate reduced the number of fat cells, especially in the abdominal region.

• Researchers showed that concentrated fish oil increased oxidation of fat by activating genes that break down fat in the mitochondria and peroxisomes.

• Lipids, Vol. 39, no 12 (2004)

EFA imbalances predispose to chronic inflammatory conditions

• The inflammatory based chronic diseases that are increasing in incidence in menopausal age women and are statistically most likely to kill them:

Arthritis IBDAuto-immune diseasesAsthmaAtherosclerosisCardiovascular diseaseCancer

DHA Supports Mitochondrial Function & Energy Production

• Mitochondria, have a substantial concentration of DHA-containing phospholipids, suggesting that these are essential for the functional assembly of the respiratory chain complexes.

• Infante JP, Hiszagh VA, secondary carnitine deficiency and impaired docosahexaenoic acid synthesis: a common demoninator in the pathophysiology of diseases of oxidative phosphorylation and beta-oxidation. FEBS Lett. 2000 Feb 18:468(1):1-5

Omega-3s reduce “silent inflammation” A primary cause of chronic disease

Problem• 75% of Americans may have “silent” inflammation• Underlying cause of conditions such as Alzheimer’s and

cardiovascular diseasesSolution

• Increase EPA-DHA consumption (AA/EPA 1.5 to 3):-Displace inflammatory compounds such as PGE2-Increase formation of anti-inflammatory compounds such

as PGE1• Reduce body fat; insulin increases stored AA which is

pro-inflammatory

Omega-3 and healthy brain function

• “People who eat oily fish or take fish oil supplements score 13 percent higher in IQ tests and are prone to healthier brain aging.”

• “The results suggest that fish oil users have younger brains than non-users. The aging of the brain is being slowed down by a year or two.”

• Dr. Lawrence Whalley (AM J Clinic Nutrition, 2004)

• American J Clin Nut Vol, 80, no 6, pp 1650-1657

Omega-3 fatty acids and neuropsychiatry

“Epidemiological evidence suggests that dietary consumption of the long chain omega-3 fatty acids EPA and DHA, commonly found in fish or fish oil, may modify the risk for certain neuropsychiatric disorders. As evidence, decreased blood levels of omega-3 fatty acids have been associated with several neuropsychiatric conditions, including Attention Deficit (Hyperactivity) Disorder, Alzheimer’s Disease, Schizophrenia and Depression…”

Young, G et al: Reprod Nutr Dev. 2005 Jan-Feb;445(1):1-28

Adult Attention and Focus may be aggravated by stress

Effect of randomized supplementation with high dose olive, flax or fish oil on serum phospholipid fatty acid levels in adults with attention deficit hyperactivity disorder. Young, GS et al Reprod Nutr Dev. 2005 Sep-Oct;45(5):549-58

These data suggest that in order to increase levels of EPA and DHA in adults with ADHD, and decrease the AA/EPA ratio to levels seen in high fish consuming populations, high dose fish oil may be preferable to high dose flax oil. Future study is warranted to determine whether correction of low levels of long-chain omega-3 fatty acids is of therapeutic benefit in this population.

DHA and Psychological Stress

DHA deficiency has been shown to-reduce catecholamine production

-lower serotonin binding affinity -reduce the number of synaptic vesselsAdministration of DHA influences behavior

and plasma catecholamine levels at times of psychological stress.

Hamazaki T et al: Lipids. 1999;34 Suppll:S33-7Anti-stress effects of DHAHamazaki T et al: Biofactors. 2000;13(1-4):41-5.

Anti-Stress Effects of DHA

• In a similar double blind two month study (study 2), we measured plasma catecholamines and cortisol of students (3 females and 4 males for the DHA group and the same numbers for the control) at the start and end of the study. In study 2 the students were under a continuous stress of final exams that lasted for two months throughout the whole study period.

• The plasma cortisol did not change in either group, but the norepinephrine concentration was significantly decreased in the DHA group (-31%), whereas it stayed at the same level in the control group. These effects of DHA intake may be applied to people under psychological stress.

• Hamazaki T et al. Biofactors 2000; 13(1-4): 41-45.

What about depression?

• Severity of depression correlates directly with the AA:EPA ratio.

• DHA deficiency has been shown to:-reduce catecholamine production-lower serotonin binding affinity-reduce the number of synaptic vessels • DHA supplementation dramatically

increases the number of synaptic vessels in nerves.

OB/GYNs are recommending EPA/DHA

• Promotes brain and eye development

• Encourages fetal weight gain

• Prevents perterm labor and preeclampsia

• Increases the nutritional value of breast milk

• Stabilizes mood and prevent depression during and after delivery – “baby blues”

DHA Reduces Post-natal Depression and May Promote Restful Sleep

• Without sufficient dietary intake, mothers become depleted of DHA and may increase their risk of suffering major depressive symptoms in the postpartum period.

• How much? – 500 mg/day pre-conception, 1st & 2nd Trimester

• -1000 mg/day 4rd & 4th Trimester1. American journal of clinical nutrition 2002;76(3):608-13

EPA-DHA Reduces Pediatric Asthma

• Maternal oily-fish intake during pregnancy was associated with reduced asthma risk among children whose mothers had a history of asthma.

• Among children of asthmatic mothers, maternal intake of oily-fish during pregnancy reduced asthma risk by 71%.

• M.T. Salam et al, Prevention Medicine USC 5/25/04

Change your oil, improve your health!

• Goal: to achieve minimum 8-10% cellular EPA/DHA level

• Achieve by supplementing 1 gram EPA-DHA per day

EPA-DHA Dosing

• Application:Adult Maintenance

Cardiovascular Health

Healthy Blood Fat Levels

Inflammation

Mental Function

Prenatal Health

Children

Adults under chronic stress

Blood sugar balance

• Daily Levels:1-2 grams EPA-DHA

1-2 grams EPA-DHA

2-4 grams EPA-DHA

2-7 grams EPA-DHA

2-10 grams EPA-DHA

1-2 grams EPA-DHA

100 mg – 400 mg DHA

1000 mg – 2000 mg DHA

Individual diet plan

Functional Medicine

“Functional medicine focuses on the early warning recognition and intervention to improve physical, mental and physiological function prior to the onset of acute disease.” Gazela, KA: “Jeffrey S. Bland, PhD, FACN, CNS: Functional Medicine Pioneer”, Alternative Therapies in Health and Medicine, Sept/Oct 2004, VOL. 10, NO. 5.

Medical foods are designed to restore function during early phases of declining health as well as manage a variety of chronic conditions and disorders by addressing underlying causes.

What is a Medical Food?

• A specific combination of whole food macronutrient derivatives, micronutrients and botanical extracts designed with a specific therapeutic goal in mind.

WHY SOY?

• Healthy body composition• Insulin resistance• Favors “Good estrogen”• Body recognizes as safe, weak estrogen• Cardiovascular health• Bone health• Antioxidant protection• Cognitive function• Hot flashes, sweats, dryness, mood, etc.

I support the use of soy

• Do to the large amount of reported safety and efficacy studies.

• Its long history of safe consumption by Asian populations.

• The FDA health claim regarding soy protein and its potential to reduce the risk of heart disease.

• Substantial data regarding the benefits of soy in cardiovascular health, prostate health, menopausal symptom relief, and bone health as well as other important areas.

Understanding Soy

• Soy has been consumes by Asian culture for thousands of years.

• Soy is a legume that is so nutritionally complete that it sustained Eastern populations through drought and famine.

• Composed of:- Protein - Carbohydrates- Fat - Fiber- Phytonutrients - Isoflavones- Other isoflavone rich foods include garbonzo

beans and sprouts (Red Clover).

The Forms of Soy

• Soy has been used and studied in various forms:

-Whole soybeans - raw and cooked-Protein isolates - with balanced and

unbalanced isoflavone content-Balanced isoflavone isolates-Single isoflavone isolates• The more imbalanced the isoflavones the

greater the chance for negative affects.

Phytosterols and Human Lipid Metabolism

“Plant sterols have been known for several decades to reduce plasma cholesterol levels. These plant materials have been granted a health claim by the FDA regarding their effects in the general prevention of cardiovascular disease”.

Marie-Pierre

Soy & Plant Sterol Research

“At a dosage of 1.8 g/day, LDL Cholesterol concentrations were 11.3% lower in the plant sterol group, and cholesterol absorption efficiency was 56% lower in the plant sterol group.”

Am J Clin Nutr 2002;76:1272-78

Soy

“…Moreover, it has been estimated…that introducing 2 g of plant sterols daily might reduce the risk of coronary heart disease by 25%...low dose of soy protein (8g) added in beta-sitosterol (2g) seems to be a practical and safe alternative for patients seeking reductions in LDL cholesterol (<15%).”

Effects of a Dietary Portfolio of Cholesterol – Lowering Foods vs Lovastatin on Serum

Lipids and C-Reactive Protein“In this study, diversifying cholesterol-

lowering components in the dietary portfolio by use of a soy protein-based, plant sterol fortified diet was as effective in lowering LDL cholesterol as was the use of lovastatin…reductions in hsCRP were significant with this dietary regime”.

JAMA 2003;290:502-10.

Is soy beneficial for breast health?

• Research is far from conclusive on this issue and researchers are urging women to be cautious

• However, a distinction should be made between the clear benefit of soy protein for cardiovascular health and the inconclusive role of isoflavones for breast tissue health.

Does soy benefit menopausal women?

• YES. The research shows a great correlation with reducing hot flashes and other menopausal issues by consuming soy products.

• Consumption of soy protein containing isoflavones decreased the intensity of hot flashes.

• The majority of studies in menopausal women have shown improvement of hot flashes following soy consumption.

Do soy products compromise male reproduction?

• NO. Studies done with balanced soy isoflavones do not show negative impact on male reproduction.

• Negative studies are done with one isoflavone or by injecting isoflavones directly into the blood create much of the negative concern on soy.

• Genistein was shown in cell cultures to negatively impact human sperm’s ability to fertilize the female egg.

• Only when plant estrogens are injected, leading to high blood levels are adverse effects seen in research animals.

Do soy products compromise male reproduction?

• Four published clinical trials investigating the effects of soy isoflavone consumption in men and reported that there are no adverse effects of soy isoflavone consumption on sperm quality.

• Consumption of isoflavone supplements at the level of 40mg daily had no effect on semen quality.

• There is no evidence of increased rates of fertility disorders among the Asian population due to soy consumption.

• Medical foods with soy deliver 17mg of balanced isoflavones per serving.

Should soy be used for prostate health?

• YES. Research shows overwhelming evidence of the positive benefits in supporting prostate health without adverse effects.

• Nagata C, Takatsuka N, Shimizu H, Hayashi H, Akamatsu T, Murase K. Effect of soymilk consumption on serum estrogen and androgen concentrations in Japanese men. Cancer Epidemiol Biomarkers Prev 2001;10(3);179-84.

• Habito RC, Montaito J, Leslie E, Ball MJ, Effects of replacing meat with soyabean in the diet on sex hormone concentrations in healthy adult males. Br J Nutr 2000;84(4):557-63.

• Mitchell JH, Cawood E, Kinniburgh D, Provan A, Collins AR, Irvine DS. Effects of a phytoestrogen food supplement on reproductive health in normal males. Clin Sci 2001;100(6):613-18.

• Hussain M et al. soy isoflavones in the treatment of prostate cancer Nutr Cancer 2003;47(2):111-7.

Does soy inhibit thyroid function?

• Well designed human clinical studies have demonstrated that soy has a minimal effect on overall thyroid function in healthy individuals.

• Ultrameal Medical Food Program: Containing soy protein (15 grams) with a comprehensive vitamin/mineral blend

• Patients using the Ultrameal product had no change in their TSH levels after 10 weeks. Patients using the popular retail product showed a significant elevation (150% above baseline) in their TSH levels.

Does soy inhibit thyroid function?

• Amounts greater than 200mg of isoflavones per day may inhibit thyroid hormone synthesis in susceptible people. (thyroid issues/low iodine)

• Certain studies suggest that soy and soy isoflavones inhibit the production of thyroid hormones in individuals with thyroid issues.

• Approximately 10 million Americans or 3% of the population have thyroid issues.

• Alternatives to soy based medical foods are available for these individuals (rice and whey, etc.)

Is soy beneficial for bone health?

• YES. Studies have shown that the isoflavones that are found in soy stimulate bone formation and reduce bone breakdown.

• Soy isoflavones have been found to have a positive effect on bone health.

• Isoflavones stimulate osteoblastic bone formation and inhibit osteoclastic bone breakdown.

Metagenics options to benefit every type of person

• Thyroid issues & soy allergy clients:

UltraMeal WHEYUltraMeal RICEUltraClearUltraClear PlusUltraInflamX

• Breast tissue health options:

EstriumUltraMeal WHEYUltraMeal RICEUltraClearUltraClear PlusUltraInflamX

Is soy beneficial for tissue health?

• YES. Soy contains various beneficial agents for tissue health.

• Cultures that eat soy have shown an improvement in colon and specific hormone-related tissue health issues.

• Human trials involving post-menopausal women demonstrate a significant shift in healthy estrogen metabolism.

Isn’t it better to use a more complete protein?

• Early studies suggested that soy was not a complete protein source. These early findings have been shown to be inaccurate.

• Soy has the same “protein digestibility” score as egg white and milk protein.

• Sarwar G, McDonough FE, Evaluation of protein digestibility-corrected a ꎜ noacid score method for assessing protein quality of � ��foods. J Assoc Off Anal Chem 1990;73(3):347-56.

Isn’t soy more allergenic than other proteins?

• Soy proteins tend to be less reactive than many other food proteins. In fact, soy has been used as an alternative for infants with allergies to cow’s milk.

• A meta-analysis of 17 studies of allergy patterns in high risk infants revealed soy allergy occurs in 3% to 4% of subjects versus 25% for cow’s milk.

Do I have to use fermented soy products to achieve therapeutic benefits?

• No. The majority of studies around the world show beneficial effects of soy.

• Our research studies support those findings for areas including:

Blood sugarBody compositionPreserving muscle mass during weight

lossCardiovascular risk reduction

Improve health with

• UltraMeal-Altered Body Composition

-Early Onset Metabolic Syndrome with Altered Body Composition

• Central body obesity

• Insulin resistance

• Altered body composition

• UltraMeal Plus-Metabolic Syndrome with Cardiovascular Syndrome • Elevated Cholesterol

• Increased Triglycerides

• Hypertension

UltraMeal Plus

• Combined with a low-glycemic-index dietary program and exercise regimen, provides nutritional support for the management of conditions associated with cardiovascular disease, including:

• Hypercholesterolemia• Hypertriglyeridemia• Metabolic Syndrome• Altered Body Composition

UltraMeal

• Combined with a low-glycemic-index dietary program and exercise regimen, provides nutritional support for the management of conditions associated with altered body composition, including:

• Dyslipidemia• Metabolic Syndrome• Hypertension• Estrogen imbalance

UltraMeal Plus 360• Multi-mechanistic nutritional support for metabolic syndrome and CVD, with

the added benefit of Selective Kinase Response Modulators (SKRMs).• Clinically tested results: The UltraMeal Plus 360 Medical Food Program was

recently shown to improve important CVD risk factors in patients with metabolic syndrome. In this clinical study, patients assigned to treatment with UltraMeal Plus 360 Medical Food Program, exercise regimen, and low-gylcemic-load (GL) diet vs. the same low-GL diet and exercise regimen alone showed:

• Statistically greater reductions in lipid parameters• Statisitcally greater reduction in serum homocysteine• Significant increase in HDL (“good”) cholesterol• Persistent lowering effects on apoB and apoB/apoA1 ratioo ApoB may be a better indicator of CVD risk than total cholesterol or LDLo ApoB/apoA1 ratio is a newly recognized, increasingly significant indicator of

CVD risk

Dynamic Combination for Overall Cardiovascular Health

Patient Profile• Patients on statin therapy• Patients 35-64 under

preventative care for CVD• Increased triglyerides• High C-reactive protein• High cholesterol

– Increased LDL– Low HDL

UltraMeal Plus2 scoops BID along with a

low glycemic diet

EPA/DHARecommended: 1 to 3

grams daily

CoQ10Recommended: 100 – 300

mg daily

Children & Young Adults(soy and whey combination)

• Ultracare FIRST START Medical Food Program

UltraGlycemX Medical Food

• Nutritional support for individuals with Type 2 Diabetes and Hypoglycemia

UltraGlycemX

• Combined with a low-glycemic-index dietary program and exercise regimen, provides nutritional support for the management of conditions associated with insulin insensitivity and elevated blood sugar levels, including:

• Type 2 diabetes• Insulin resistance• Hypoglycemia• Hypertension

Blood sugar

• Blood sugar refers to levels of glucose in the blood.

• Blood sugar concentration, or serum glucose level, is tightly regulated in the human body.

• Glucose transported via the bloodstream is the primary source of energy for the body’s cells.

Fasting & 2 hr postprandial glucose following a 75 gram glucose load

• Fasting• 80-90 optimal

• 105 and above = DMII

• 2 hour postprandial• 80-120 optimal• Below 80 =

hypoglycemia• 120 and above =

DMII

Glucose levels

• 35 = extremely low, danger of unconsciousness• 75 = slightly low, first symptoms of lethargy etc.• 80-90 = optimal pre-prandial in non-diabetics• 80-120 = ooptimal 2 hour post-prandial in non-

diabetics• Above 100 = look for Metabolic Syndrome

criteria• 400 = max mg/dl for some meters & strips• 600 = high danger of severe electrolyte

imbalance

Blood sugar important points

1) “high fructose corn syrup,” which is simply a Pure fructose (what we use) is NOT the same as replacement for table sugar. Fructose is “natural” and is the typical carbohydrate found in fruits and sone vegetables.

2) The fructose in UltraMeal and UltraGlycemX is nutritive (ie, food) and is NOT used as a sweetener. It is there for its therapeutic benefit.

3) “Moderate” consumption of fructose is associated with POSITIVE blood sugar, triglyceride, and body composition benefits.

Blood sugar important points con’t

1) Data from animal studies use fructose levels far higher than a human would consume in a day – the equivalent of up to 700 calories in a day from fructose alone.

2) We have the clinical proof in numerous studies that moderate fructose consumption shows health benefits.

3) The obvious problem is poor diet – one FULL of empty calories from processed foods and beverages and NOT from a quality, balanced, meal such as UltraMeal or UltraGlycemX.

Definition of Glycemic Index

• Glycemic index (GI) is defined as the incremental area under the blood glucose curve in response to a standardized carbohydrate load. It is therefore an index of the blood glucose raising potential of the available carbohydrate in a food.

Many factors affect GI of a food:

• Carbohydrate type-Simple: glucose, fructose, maltose-Complex: amylose, amylopectin• Fiber content and type• Processing (the higher the processing, the

higher the GI load)• Physical nature• Other macronutrients in food-Protein-Fat

Glycemic Index

• The GI for a particular food is derived by expressing the individual glycemic index as a percent of a reference food, typically white bread or glucose.

Glycemic Index and Obesity

Low GI foods control appetite and delay hunger.

Low GI diets reduce insulin levels and insulin resistance.- High-carb, low-fat diets increase postprandial

hyperglycemia and hyperinsulinemia.

Several human studies found that energy restricted low-GI diets produced greater weight loss than did equivalent diets based on high GI foods.

Brand-Miller JC et al. Glycemic index and obesity. AM J Clin Nutr, 2002. 76(1): p. 281S-5S.

Glycemic Index and HDL-Cholesterol

• Conclusion: dietary GI is a stronger predictor than dietary fat intake of serum HDL-cholesterol concentration.

• Frost G et al. Glycaemic index as a determinant of serum HDL-cholesterol concentration. Lancet, 1999. 353(9158): p. 1045-8.

A meta-analysis of Low-GI Diets in the Management of Diabetes

• 14 studies that met inclusion criteria• Conclusions:-Low GI diets have a clinically useful effect on

medium-term glycemic control in patients with diabetes.

-The benefit is similar to that offered by pharmacological agents that also target postprandial hyperglycemia.

*Without drugs they get “similar” results on low GI diet

Brand-Miller et al. Low-Glycemic Index Diets in the Management of Diabetes: A meta-analysis of

randomized controlled trials. Diabetes Care, 2003 26(8): 2261-2267

Glycemic Index

Low GI 55 or less

Medium GI 56 to 69

High GI 70 or more

Glycemic Index of Selected Foods(referenced to glucose)

• Watermelon 72• Pearled barley 25• White flour bread 70• Carrot 47• Cornflakes 72• Baked potato 85• Apple 38• Apple juice 40

Glycemic Load

• The amount of carbohydrate often differs in a typical serving of a food.

• A measure termed ‘glycemic load’ (GL) has been introduced.

(Salmeron J, Ascherio A, et al. Dietary fiber, glycemic load, and risk of NIDDM in men. Diabetes Care, 1997. 20(4): 545-50.

• The dietart glycemic load is defined as the product of a food’s glycemic index and its carbohydrate content.

GL=(GI divided by 100) x available carb

• Example: Watermelon (GL=4)

- Glycemic index = 72. A typical serving (120 grams or ¾ cup) has 6 grams of available carbohydrate.

- Glycemic load = (72 / 100) x 6 = 4.32 (rounded to 4).

Glycemic Load

Low GL 10 or less

Medium GL 11 to 19

High GL 20 or more

GL=(GI/100) x available carb(available carbohydrate content of typical serving)

• Example: Carrot (GL = 3)

- Glycemic index = 47. A typical serving (80 grams or ½ cup cooked) has 6 grams of available carbohydrate.

- Glycemic load = (47/100) x 6 = 2.82 (rounded to 3)

GI/GL Comparisons

FOOD GI GL

Baked potato 85 26

Watermelon 72 4

Apple 38 6

Apple juice 40 11

Carrot 47 3

GI & GL values of hundreds of foods have been determined

• On the web:

www.glycemicindex.com

www.mendosa.com

Effects of a Low-Glycemic Load Diet

“Resting energy expenditure decreased less with the low-glycemic load diet than with the low-fat diet…participants receiving the low-glycemic load diet reported less hunger…”

“Insulin resistance, serum triglycerides, C-reactive protein, and blood pressure improved more with the low-glycemic load diet.”

“In conclusion, we found that the physiologic adaptations to a weight loss diet thought to antagonize weight loss, involving energy expenditure and hunger, can be modified by dietary composition.”

JAMA 2004:292(20)2482-2490

High Glycemic Index Foods, Overeating, and Obesity

“Voluntary energy intake after the high-GI meal…81% greater than after the low-GI meal.”

Pediatrics 1999; 103(3):E26

GI Meals

“high-glycemic index meals produce an initial period of high blood glucose and insulin levels, followed in many individuals by reactive hypoglycemia, counter-regulatory hormone secretion, and elevated serum free fatty acid concentrations. These events may promote excessive food intake, beta cell dysfunction, dyslipidemia, and endothelia dysfunction.”

JAMA 2002:287(18);2414-2423

Fiber

• Two isocalorically equal diets varying only in amount and type of fiber (50 g at 1:1 soluble/insoluble vs 24 g at 1:2 soluble vs. insoluble) for 6 weeks in non-insulin diabetes patients.

• The high-fiber diet lowered the area under the curve for 24-hour plasma glucose and insulin concentrations by 10 percent and 12 percent respectively.

• Chandala, M., et al., Beneficial effects of high dietary fiber intake in patients with type 2 diabetes

mellitus. N Engl J Med, 2000. 342(19):1392-8.

FAT

• High-monounsaturated-fat diets reduced fasting triglycerides (19%) and VLDL-cholesterol (22%), and caused a modest increase in HDL-cholesterol concentrations with no adverse affect on LDL-cholesterol.

• No evidence that high-monounsaturated fat diets induce weight gain in patients with diabetes mellitus provided that energy intake is controlled.

• Garg, A., high monounsaturated fat diets for patients with diabetes mellitus: a meta-analysis. AM J Clin Nutr, 1998. 67(3 Suppl): p. 577S-582S.

Healthy vs Unhealthy

• Normal MetabolismHealthy body

compositionGreat energyHealthy attitudeGreat mental function

• Metabolic SyndromeMental fogginessLow energyDepression Increased fatDecreased muscle

mass

Detoxification & InflammationUltraClear UltraClear Plus

• Fatigue

• Food allergies

• Environmental toxicity

• Liver function

• Health maintenance

Elimination of Toxins

• UltraClear Plus

Nutritional Support Is required for Proper Clearance of Toxins

• “Diets restricted in calories, protein, … as well as those having low quality protein or high sugar content, can affect the component enzymes, ctochrome P-450 and the cytochrome P-450 reductase, … In addition, deficiencies of specific vitamins (riboflavin, ascorbic acid, and Vitamins A and E) and minerals (iron, copper, zinc, and magnesium) affect the components and activities of the system.”

• Bidlack WR, Brown RC, Mohan C. Fed Proc. 1986 Feb;45(2):142-8.

Detoxification

• UltraClear

• UltraClear Plus

• UltraClear Plus pH

• AdvaClear

These help with chemical toxicity, food allergies, liver function, fatigue

GI Dysfunction: Increasing liver stress

• Patients with leaky gut, mediated food allergies, inflammation may have hepatic (liver) stress.

• In these scenarios, the liver is constantly burdened by toxins and allergens arriving from the gut.

• These patients will benefit from a program to restore normal gut barrier function to relieve the burden on the liver before they can become well.

How the environment affects genetic expression

• Poor diet

• Stress

• Fatigue

• Lack of exercise

• Drugs, alcohol, tobacco

• Chemical exposure

UltraClear Plus

• A clinically tested detoxification program to:

1. Reduce toxic load (external sources of toxins)

2. Improve Biotransformation (supports cytochrome p450 phase 1 and conjugation phase 2 pathways

3. Support elimination (optimal excretion of toxins)

AdvaClear

• This formula is particularly valuable in patients who score over 100 on the MSQ as they often have overactive Phase 1 activity and depleted conjugation pathways. Ingredients include

- Pomegranate- Watercress- Artichoke- Milk thistle- Green tea

Estrium

Scientifically designed to:

• Promotes healthy hormone cycles

• Relieves symptoms of PMS

• Promotes healthy estrogen metabolism and excretion

• Modifies the effects of circulating estrogens

Estrium

Patient Benefits

• Reduction in PMS symptoms

• Case studies show effective for symptoms associated with menstrual tension, menstruation and endometriosis

• Easy to use – 2 scoops one to two times daily mixed with juice, milk or milk substitute as meal replacement or snack

Ideal Foods That Modify Estrogen Metabolism

• Cruciferous vegetables: broccoli, cabbage, brussel sprout

• Fresh greens and vegetables (assorted colors)

• Fresh fruit: berries, melons, citrus

• Legumes: soy – tofu, soymilk, miso, tempeh, steamed soy beans (edamane), garbanzo

• Beans• Raw seeds and nuts: flax

seeds• Whole grain: oats, whole

wheat or rye berries• Quality proteins: fish,

(tuna, salmon, haddock), hormone free chicken, beef

• Oils: flax seed (ALA, Omega-3), olive, sesame

If you have InflammationUse UltraInflamX

• Rheumatoid arthritis

• Inflammatory bowel disease

• Fibromyalgia

• Eczema & psoriasis

• Asthma

Additional Inflammatory Support

• Estrium

• Kaprex

• Kaprex AI

• Inflavinoid

• Inflavinoid Intensive Care

• ChondroCare

• Essential Fatty Acids

Inflammatory Cytokines, Hyperinsulinemia & Atherosclerosis• A number of studies have demonstrated

that increases in inflammatory mediators like IL-6 and hs-CRP are associated with insulin resistance and metabolic syndrome.

• Metabolic syndrome is strongly associated with the onset of endothelial dysfunction, which may explain why type-2 diabetes is a risk factor for atherosclerosis.

If you have

• Altered body composition

• Abnormal blood sugar regulation

• Cardiovascular risks (atherosclerosis)

Consider UltraMeal Plus, UltraInflamX

Nitric Oxide prevents Atherosclerosis and Promotes Circulatory Health

• Dilating the arteries and increasing blood flow support circulatory function for a healthy heart.

Support healthy blood pressure, circulation & heart muscle function

• Arginine

• 5-MTHF

• Magnesium Bonito Peptides

Arginine Imperative for Heart Health

• Is an amino acid• Is naturally found in red meat, poultry, fish, and

diary• Supports the production of nitric oxide, which is

used to dilate blood vessels• Maintain health of the circulatory system• Is used for cardiovascular conditions:

– Congestive heart failure– Hypertension– Coronary artery disease

Magnesium & Folatemost researched ingredients for the heart

Magnesium• Supports healthy

endothelial cells• Alleviates arrhythmias &

heart palpitations• Essential for proper heart

muscle function• Lowers triglyerides• Raises HDL• Lowers cholesterol

5-MTHF• Improves nitric oxide

status• Lowers blood levels of

homocysteine• Crucial for methylation• Reduces risk of heart

disease• Influences endothelial

function

New Atherosclerosis Concepts

• Understanding the impact on the vascular tissue through inflammatory-immunological mediated trauma

• The association with the abnormal lipid/cholesterol panel and risks for MI

• The presence of inflammatory cytokines

Ornish D et al: JAMA. Vol. 280, No. 23, pp. 2001, dec. 16, 1998

• Intensive lifestyle changes (10% fat, whole foods vegetarian diet, aerobic exercise, stress management training, smoking cessation and group psychosocial support) resulted in regression of coronary atherosclerosis over a five year period, whereas for those in the control group using the traditonal AHA approach CHD continued to progress and more than twice as many coronary events occurred.

Using medical food shakes twice daily

• Predictability – clinically tested and utilized in thousands of clinics worldwide

• Well tolerated by the most sensitive client – easily digested and low allergy potential

• Convenient – good taste and easy to follow programs

Cardiovascular support

• EPA/DHA• Cardiogenic (CV Wellness Essential)• CoQ10• Lipid support- Lipogen- Meta sitosterol 2.0- Lipotain- Cholarest

Therapeutic dosing levels for cardiovascular health

• Arginine 3000 – 6000 mg

• Magnesium 200 – 400 mg

• ActiFolate 400 – 800 mcg

CoQ10

• Ubiquinone (CoQ10) is a vitamin-like fat-soluble antioxidant found in all cells in the body.

• Statin therapy for cholesterol, lowers the body’d production of CoQ10.

• CoQ10 deficiency may cause increase risk of heart disease and high blood pressure.

• Adequate CoQ10 intake is vital for organs such as the heart, liver, kidney and pancreas.

• As you age the CoQ10 is depleted.• CoQ10 is key for mitochondrial function.

CoQ10: Dosage Range100-300 mg daily

• Protects patients on Statin therapy• Effective nutritional treatment for

congestive heart failure• Antihypertensive effects• High doses may reduce functional decline

in early Parkinson’s disease• May prevent migraine headaches• Master antioxidant-may support breast

tissue health

Dr. Jeffrey Tucker’s Program

• Simple lifestyle changes• Facilitates transition to healthy, whole food

diet• Replaces problem meals with a healthy

shake• Understand the relationship of health and

food• Food choices from every category (meats,

vegetables, fruit, grains, etc)

Dr. Jeffrey Tucker’s Program Diet & Exercise

• Low gylcemic index foods

• Small, frequent meals

• Medical food for body composition

• Quality EFAs, esp. omega 3 (EPA, DHA)

• Exercise –progressive body movement

-CORE, Gymstick, free weight training

• Additional supplementation as needed

Why is this the most effective program?

• Better appetite control• Delayed hunger• Less cravings• Better blood sugar control• Improved insulin sensitivity • Better reduction of elevated blood lipids,

blood pressure & blood sugar• The most specific exercise training

Clients that will benefit from Dr. Tucker’s program

• Altered body composition (come in to the office and do a BIA test)

• Abnormal blood sugar regulation• Cardiovascular risks (atherosclerosis,

hyperlipidemia, dyslipidemia)Consider: UltraMeal Plus for increased cholesterol

and LDL.UltraMeal + MetaglycemX/Insinase or

UltraGylcemX + Insinase for increased Trig/HDL ratio

Illness and Muscle Loss

• “…we found that fat-free mass was lower and fat mass was higher (Sarcopenia) in acutely ill and chronically ill patients than controls.”

• J Amer Diet assoc 2002;102(7):944-955

• The over-fat “ill” with sarcopenia include those with fatigue, arthritis, back pain, metabolic syndrome, cardiovascular disease, hypertension, diabetes and other health problems.

Sarcopenia – understanding the Dynamics of Aging Muscle

• The damage caused by high glycemic meals insulin resistance, inflammatory immune factors and hormone changes acting primarily in the postprandial state are implicated as an important cause of sarcopenia.

• JAMA 2001:286(10):1230-31.

10 week Doctor Supervised Programvs.

Un-supervised ProgramTotal weight

Lean Body Mass

Change In Fat Weight

Dr. Supervised

-11 LBS +4 LBS -15 LBS

Over The Counter

-13 LBS -11 LBS -.91 LBS

10 week Doctor Supervised Programvs.

Un-supervised Program“Two statistically significant differences

between the groups were changes in thyroid stimulating hormone (TSH) and body composition (BC). No change in TSH was observed in the DSP group pre- and post-intervention. Whereas a significant increase (150%) was observed in the OTC group. In addition, participants in the DSP group last significantly more fat than the OTC group.”

UltraMeal has the science…

All Women:• Lost body weight 5.7-22 lbs• Decline in % body at up to 10.1%• Lost fat mass up to 22.9 lbs• Average fat loss 14.1 lbs• 12 of 18 showed increase in lean body mass .2 – 7.7 lbs Robert Hackman, PhD Associate Professor of Nutrition University of Oregon

250 Esslinger Hall Eugene, OR.

UltraMeal Soy Protein Source

• Conditions associated with Metabolic Syndrome

• Delicious Flavors & Variations- Banana Blast- Dutch Chocolate- Strawberry Supreme- Vanilla- Country Peach- Raspberry- Mocha- Also available in Rice & Whey

Protein

• UltraMeal in convenient Bar Form

-Chocolate Raspberry

-Lemon Zinger

-Chocolate Fudge

-Apple Cinnamon

-Chocolate Banana

UltraMeal: Additional Facts

• Glycemic Index of 31

• Optimal, foundation nutrition with all essential vitamins and minerals

• Dairy-free source of calcium for bone health (500mg per serving = 2 scoops)

• Features ActiFolate, a proprietary blend of active floates for healthy methylation

Cardiovascular Disease Facts

• Cardiovascular disease is the #1 killer in U.S.• Nearly 62 million have at least one type of CVD• More Dr. office visits for hypertension or high

blood pressure, than for any other reason• Economic cost of CVD is approximately 298

Billion, more than 28 Billion was spent on CVD Drugs.

Soy & Plant Sterol Research

“At a dosage of 1.8 g/day, LDL cholesterol concentrations were 11.3% lower in the plant sterol group, and cholesterol absorption efficiency was 56% lower in the plant sterol group.”

Am J Clin Nutr 2002;76:1272-78

UltraMeal Plus Program Better Than AHA Diet For Reducing 14 Cardiovascular Risk Factors

• Human Clinical Trial Demonstrates…

Trial conducted at the Functional Medicine research Center, a research arm of Metagenics.

UltraMeal Plus & Dr. Tucker’s Workout Program in Reducing 14 Cardiovascular Disease Risk Factors

• UltraMeal PlustChol -16%LDL-C -15%HDL-C +6%Trig -45% tChol/HDL-C -20%TG/HDL-C -45%Body weight -14.8lb% Lean Mass +2.8%Hs CRP -34%HbA1C -3.4% Fasting Insulin -26%BP systolic -4.6BP dyastolic -8.3

• AHA Diet-1%-2%+1%-24%-4%-24%-7.5lb+1.23%-7%-1.5%-10%-2.3-6.0

UltraMeal Plus & Dr. Tucker’s Program

• Reduction in 14 important cardiovascular disease risk factors including cholesterol, HDL, triglyerides, blood pressure.

• 97% greater weight loss tha aleading diet used by doctors worldwide (ADA diet).

• 110% greater fat loss than a leading diet used by doctors worldwide (AHA diet).

UltraMeal Plus

• Patients lost weight while maintaining muscle, resulting in improved body composition.

• Promotes healthy blood sugar balance – low glycemic index meal.

• Preserves lean body mass – unlike most diet and weight loss programs, patients lose fat and maintain muscle.

The Truth About Type 2 Diabetes

• 20.8 million children and adults have diabetes- 14.6 million diagnosed- 6.2 million are unaware• Results from insulin resistance• The body’s cells are resistant to the actions of

insulin• Pancreas produces too little insulin• Diabetics usually develop the condition after age

45• About 18% of U.S. population 65 and older has

diabetes.

UltraGlycemXGlycemic Index of 36

• Nutritional support for individuals with Type 2 Diabetes & Hypoglycemia

• Provides enhanced levels of:-Cinnamon-Vitamin E, biotin, vanadium, magnesium,

chromium, and alpha-lipoic acid• High quality protein, carbohydrates, and fat in

shake form• Inclusion of specific fibers• Is free of dairy, lactose, wheat, gluten

UltrGlycemX supportive vitamins & minerals

• Alpha-lipoic Acid- Stimulation of Glucose Transport Proteins- Improves insulin receptor sensitivity- Increases glucose metabolism in mitochrondria• Zinc and Chromium Combination- Reduces oxidative stress in patients with blood sugar

concerns• Vanadium- Activates cellular insulin receptor pathways• Taurine- Protects the beta cells in the pancreas- Stimulates insulin sensitivity

Cinnamon in UltraGlycemX

“This study demonstrates that intake of 1, 3, 6 g of cinnamon per day reduces serum glucose, triglyerides, LDL cholesterol and total cholesterol in people with Type 2 diabetes and suggests inclusion of cinnamon in the diet of people with type 2 diabetes will reduce the risk factors associated with diabetes and CVD.”

Green Tea Therapy forInsulin Resistance

Green Tea in UltraGlycemX• Antioxidant• Appetite regulation• Leptin receptor independent pathway• Stimulates respiration and energy

expenditure• Stimulates adipose tissue thermogenisis• Fat burning

Green Tea in UltraGlycemX

“Epigallacatechin gallate (EGCG), a major ingredient in green tea…was reported to functionally act as antidiabetic. Injection of EGCG into lean and obese Zucker rats significantly lowered blood glucose and insulin levels, and green tea extract increased glucose metabolism in adipocytes (fat cells).”

Experimental and molecular Medicine Vol. 35, No 2, 136-139 April 2003

UltraGlycemX supportive vitamins & minerals

• Biotin- Supports metabolism of glucose without increased insulin secretion- Improves beta cell function- Enhances post-prandial glucose uptake by the liver and skeletal

muscle• Alpha-lipoic Acid- Stimulation of Glucose Transport proteins- Improves insulin receptor sensitivity- Increases glucose metabolism in mitochrondria• Chromium- Enhances cell membrane fluidity- Stimulates glucose uptake- Allows for proper binding of insulin to receptors

UltraGlycemX supportive vitamins & minerals con’t

• Zinc & chromium combination

- Reduces oxidative stress in patients with Type 2 diabetes.

• Vanadium- Activates cellular insulin receptor pathways• Taurine- Protects the beta cells in the pancreas- Stimulates insulin sensitivity

UltraGlycemX

• Hypoglycemia• Dizzy after skipping a meal• Sugar cravings• Low energy

Parameters:• Fasting glucose >100mg/dl and <110mg/dl• Triglycerides >150mg/dl and <175mg/dl• BP < 140/90

Which Medical Food To Use

• BODY COMPOSITION MANAGEMENTUltraMeal, First Start• CARDIOVASCULAR DISEASE & BODY

COMPOSITIONUltraMeal Plus• DYSGLYCEMIA & INSULIN RESISTANCEUltraGlycemX, UltraMeal 360• INFLAMMATIONUltraInflamX, UltraInflamX 360• DETOXIFICATIONUltraClear, UltraClear Plus, UltraClearPlus pH, Estrium

UltraGlycemXType 2 Diabetes

Insulin resistance

Hypoglycemia

Hypertension

UltraMeal Plus

Hypercholester-olemia

Hypertriglycer-idemia

Metabolic Syndrome

Altered body composition

UltraMeal

Dyslipidemia

Metabolic syndrome

Hypertension

Estrogen imbalance

Biochemical

Challenge

Wellness

EssentialsMedical Food Micronutrients Supportive

supplements

Maintenance

General Wellness

Original, Woman’s, Pregnancy, Men’s

Ceralin forte

Body composition

Original

Blood Sugar

UltraMeal EPA/DHA

Insulin resistance

Blood Sugar UltraMeal Plus (pH), UltraGlycemX

MetaGlycemX EPA/DHA, Insinase, Ceriva

Metabolic

Syndrome

Blood Sugar UltraMeal Plus (pH), UltraGlycemX

MetaGlycemX EPA/DHA, Insinase, Ceriva

Dyslipidemia Cardiovascular

Blood Sugar

UltraMeal Plus (pH), UltraGlycemX

Metasitosterol 2.0

EPA/DHA, CoQ10, Lipotain

Inflammation Original, Joint UltraInflamX InflavinoidInflavinoid Int. Care

EPA/DHA, Kaprex, Kaprex AI, IsoD3, Trancor, Ceralin Forte

Biotransformation

(Detoxification)Original UltraClear Plus

(pH), UltraInflamXAdvaClear Silymarin,

Chloraclear

Methylation Original UltraMeal Plus (pH),

EstriumAdvaClearEstroFactors/Testralin

Glycogenic

Female Hormones

Women’s Estrium EstroFactors MetaI3C, Ceriva

Male Hormones Men’s UltraMeal Plus Metasitosterol 2.0

Tribulus synergy, Testralin

Why Stress Reduction?• Stress accounts for 75-90% of all primary care visits in the

US (National Inst for Occupational Safety and Health)

• Almost all illness is stress-related

- caused by stress

- aggravated by stress

- causes stress• #1 reason why people eat poorly and quit healthy life

style programs• Conserves energy• Restores sense of control• Supports good choices• Reduces cortisol

What do people do to manage mental stress

Self-medicate through…• Drug or alcohol abuse• Tobacco use• Abnormal patterns• Passive activities (couch potato, video games)• Over-eating, over-working, over-sleeping• Stimilants, e.g. coffee - Four or five cups daily can cause changes in blood

pressure and stress hormone levels similar to those produced by chronic stress

(self-perpetuating the stress cycle)

Or, go to their Doctors for Rx

to manage mood or stress-related illness • Anti-depressants SSRIs SNRIs NDRIs Tricyclic antidepressants Receptor blockers MAOIs

• Anti-anxiety medications

• Anti-inflammatory

• Anti-ulcerant

• Cholesterol reducers

• Anti-hypertensives

Depression & Anxiety DisordersNational Institute of Mental Health, Information Resources and Inquires Branch

website:www.nimh.nih.gov

• DepressionIn an given 1 year period, 9.5% of the population,

or 18.8 million American adults suffer from a depressive disorder.

Affects about 12.4 million women and over 6 million men in the US each year

• Anxiety DisordersApproximately 19 million American adultsChronic, relentless and grows progressively worse

if not treated

North America Top Selling Drug Category

• Central nervous system category (anti-anxiety, antidepressants, anti-

psychotics)2005 retail sales: $43.3 billionGrowth: 23.0%12.2% of all drug sales

www.imshealth.com

FDA Warning:

• Anti-depressants linked to suicidal behavior in depressed children and adolescents.

• The warning applies to both children and adults and includes the following drugs:

Prozac Lexapro

Zoloft Wellbutrin

Paxil Effexor

Luvox Serzone

Celexa Remeron

What is Stress?

• A physiologic response to a demand for change

• “Fight or Flight” response

• General Adaptation Syndrome

• Sympathetic Nervous system Dominance

Stress PhysiologyHans Selye, M.D., Ph.D.

• “Without stress, there would be no life”

• “Stress = nonspecific response of the body to any demand.”

How can stress cause so much damage?

Selye’s General Adaptation SyndromeThe 3 Stages of Stress

• Arousal RapidRapid increases in catecholamines (alarm molecules) SlowerSlower increases of corticosteroids (stress steroids)• AdaptationCharacterized by sustained increased levels of corticosteroids and

alarm moleculesAltered glucose tolerance, blood pressure, thyroid hormone and sex

hormone metabolism• ExhaustionDegenerative diseases characterized by the adverse influence of

corticosteroids and alarm molecules

Stress versus theRelaxation Response

Fight or Flight Response• Sympathetic State Inc. Heart Rate Inc. Blood Pressure Inc. Respiratory Rate Dilated Pupils Muscle Tension Inhibits Digestion

Relaxation Response• Parasympathetic State Dec. Heart Rate Dec. Blood Pressure Dec. Respiratory Rate Constricted Pupils Muscle Relaxation Enhances Digestion

Stress

• The basis for human stress related disease is the high percentage of time spent in the sympathetic dominant state.

Sympathetic Dominance:Long-term Effects of Elevated Cortisol & Catecholamines

• GI distress: IBS, ulcers• Cardiovascular symptoms:

rapid pulse, pounding heart, weakness, dizziness, chest pain, high BP

• Mood changes: general irritability, floating anxiety, depression, impulsive behavior, nervous laughter, increase startle response

• Hyper-kinesis or –excitation• Sleep disturbances:

nightmares, insomnia• Brain architecture changes:

Lower hippocampal volume (inc cortisol)

• Cognitive impairment: inability to concentrate, poor memory

• Neuromusculoskeletal complaints: TMJ, bruxism, trembling, nervous ticks, back and muscle ache

• Energy level: Fatigue of unknown origin

• Adrenal architecture changes: Adrenal hyperplasia “burnout”: dryness of mouth, sweating, salt cravings

• Immune impairment: increased susceptibility to viral infections, autoimmune disorders

Stress…Not Just An Adrenal Problem

• Stress triggers psycho-neuroendocrine-immune imbalances

Applied Nutrition Science Reports No. 576

Emotional trauma Limbic system Hypothalums

Locus Coenuleus Primary Afferent Nociceptor Noxious Stimulus

Emotional trauma Limbic system Hypothalums

Norepinephine (NE) Sympathetic Nervous System

Corticotrophin Releasing Hormone (CRH) Anterior Pitutiary AdrenocorticotrophinAdrenal cortexCortisol

Cortisol

• Increases with age and can elevate blood glucose by up to 50%, contributing to insulin resistance and inflammation.

Cortisol Influences Neuroendocrine Function

• Inc. Epinephrine (E) & Norepinephrine

• Inc. Cortisol• Inc. Insulin (due to inc.

glucose)• Inc. visceral fat deposition• Dec. TSH, T4, T3• Dec. estrogen,

Testosterone, Progesterone

• Altered neurotransmitter balance

• Inc. oxidative stress• Inc. inflammation• Inc. need for

detoxification• Impaired immunity- Dec. Secretory IgA- Inc. Antigen penetration- Inc. IgG- Dec. NK cell activity- Dec. IL-2- Inc. bone loss

Sympathetic Dominance Can TriggerHPA Hypoactivation

• Glucocorticoid receptor insensitivity or under production of cortisol (adrenal insufficiency)

Symptoms and conditionsFatigue/malaiseRisk of inflammatory conditionsRisk of autoimmune diseaseMyocardial infarctionUnable to perform routine tasksInability to copeApathyAnorexiaWeight lossRestless sleepWeaknessChronic painReduced libido

Sympathetic Dominance Can TriggerHPA Hyperactivation

• Cortisol and catecholamine excess and imbalance

Symptoms and conditionsAnxietyAgitation/irritabilityRestless sleepIncreased cholesterolIncreased triglyeridesIncreased blood pressureInsulin resistanceReduced libidoFatigueDepression

Impaired memory learningGastrointestinal disordersCentral obesityNeurologic disordersLoss of muscle toneDecreased growthProtein wastingBone lossSkin disordersReduced immune defensePoor injury/illness recoveryReduced sex hormone levelsReduced reproductive functionFunctional renal problems

Sympathetic Dominance Can Trigger…

• HPA Hypoactivation

• HPA hyperactivation

• Adrenal Exhaustion – adrenal gland hyperplasia and failure to respond.

Stress PhysiologyConditions Linked with Overproduction & Underproduction of Cortisol

Overproduction• Cushing’s Syndrome• Depression & OCD• Diabetes• Sleep deprivation• Anorexia nervosa• Excessive exercise• Childhood abuse• Hyperthyroidism

Underproduction• Seasonal depression• CFIDS• Fibromyalgia• Hypothyroidism• Tobacco withdrawal• Allergies/Asthma• Rheumatoid arthritisB. McEwen. The End of Stress as We Know It.

2002, p.64

Identify Antecedents, Triggers & Biological Mediators

• Antecedents: genetics, experiences, past illnesses, occupational exposure, nutrition, lifestyle

• Triggers: psychosocial, work relations, trauma

• Biological Mediators: cortisol, insulin, catecholamines, cytokines, sex steroids

Recognize signs of physical and mental stress

• Anxiety• Back pain• Constipation• Diarrhea• Depression• Exhaustion• Fatigue• Headaches• High blood pressure

• Insomnia (disturbed sleep)

• Relationship problems (i.e. loss of sexual desire)

• Shortness of breath• Stiff neck• Upset stomach• Weight gain• Weight loss• Worrying

Identify Stress Arousal Triggers

Psychological Stressors-Divorce-Unemployment -Death-Children, etc.-Self-esteem Environmental Stressors-Chemical/toxic-Infection-Endobiosis-Noise-Light-Vibration

Metabolic Stressors-Nutritional (need beyond supply,

supply beyond need)-Oxidative-InflammatoryPhysiological stressors-Structural-Traumatic-Pain-Excess exercise-Poor sleep

Stressors have different effects depending on…

• Dose

• Pattern

• Duration

• Gender: Fight vs. Flight contrasted with Tend & Befriend

Subclinical Hypothyroidism

• Subclinical hypothyroidism is more common than overt hypothyroid in elderly, especially women

• Subclinical hypothyroidism (inc. TSH in the presence or normal T concentrations)

• Increasing evidence to suggest a predisposing factor for depression, cognitive impairment and dementia

Davis JD et al: Current Psychiatry Reports (2003)S:384-390

Stress & ImmunityDynamic Balance = Health

• Th1 dominance = tissue/organ specific autoimmune disorders, delayed hypersensitivity reactions

• Th2 dominance = allergic & atopic conditions, systemic autoimmune disorders

• Th3 imbalance = immunosuppression in allergies and autoimmunity

Th1, Th2, Th3

Th1• IL-12• lL-2• TNF-alpha• IFN-y

Th3• Gut mucosal cells• Balance Th1 & Th2

Th2• IL-4• IL-5• IL-6• IL-9• IL-10• IL-13

Th1 and Th2Th1 Dominant Responses (Tissue

specific)• Hashimoto’s thyroiditis• Multiple sclerosis• Type 1 diabetes • Acute allograft rejection• Vitilligo• Alopecia• Crohn’s disease• Psoriasis• Sjogrens syndrome• Unexplained recurrent abortions

Th2 Dominant Responses(systemic)

• Allergies, hayfever• Rhinitis, Urticaria• Systemic Lupus Erythaematosis• Haemolytic anaemia,

Thrombocytopenia• Scleroderma, Sarcoidosis• Chronic Fatigue• IBS• Graves disease• Asthma• Eczema• Infections• Tumors• Successful pregnancy

Stress Hormones, Th1/Th2 patterns, Pro/Anti-inflammatory Cytokines and

Susceptibility to Disease• “Acute stress might induce pro-

inflammatory activities of certain tissues through the neural activation of the corticotropin-releasing hormone-mast cell-histamine axis”

Ilia J. Elenkov and George P. Chrousos

Cytokine Hypothesis of Depression

“There is growing evidence that depression can directly stimulate the production of proinflammatory cytokines that influence a spectrum of conditions associated with aging…”

Kiecolt Glaser JK et al. Depression & immune Fnction. J Psychomsom Res. 2002;53(4):873-6

“The ‘cytokine hypothesis of depression’ implies that proinflammatory cytokines represent the key factor in …depressive disorders.”

Schiepers OJ, et al. cytokines and Major Depression. Prog Neuropsycho Biol Psychiatry. 2005;29(2):201-17

Depressed Healing, Cytokines and Hostility

“Couples who demonstrated consistently higher levels of hostile behaviors across both their interactions healed at 60% of the rate of low-hostile couples.’

Kiecolt-glaser JK, et al Hostile marital interactions, proinflammatory cytokine production, and wound healing. Arch Gen psychiatry. 2005;62(12):1377-84

“Even a modest number of depressive symptoms may sensitize the inflammatory response in older adults and produce amplified and prolonged inflammatory responses.”

Glaser R et al. Mild depressive symptoms are associated with amplified and prolonged inflammatory responses after influenza vaccination in older adults. Arch Gen Pstch. 2003;60(10):1009-14

Balanced Biological MediatorsWith Personalized Therapeutic Lifestyle Change

Programs

1. Dec. total load of HPA/HPT triggering factors

2. Reduce HPA/HPT hyper-reactivity

3. Improve detoxification of glucocorticoids and catecholamines

4. Improve cortisol sensitivity

5. Improve insulin sensitivity

6. Support thyroid hormone production, metabolism and tissue sensitivity manage cholesterol levels

Reducing stress hormones affects mood

• Antagonizing CRF (corticotrophin releasing factor) and glucocorticoid receptors may be effective in treating depression.

• Mechanism – interruption of reverberating neuroendocrine loops involving the HPA axis and several areas of the brain (prefrontal cortex, amygdala, hippocampus, and hypothalamus)

Obesity and moods

• Obesity is associated with an approximately 25% increase in odds of mood and anxiety disorders and an approximately 25% decrease in odds of substance use disorders. Variation across demographic groups suggests that social or cultural factors may moderate or mediate the association between obesity and mood disorder.

• Arch Gen Psychiatry. 2006;63:824-830

Manage stress naturally-core functional approach

• Eating habits

• Diet

• Specific nutrients

• Plant adaptogens

• Cognitive techniques to alter stress perception

• Exercise

Food Improves Mood by Buffering the Stress Response

• Skipping meals, GI Dietlow blood sugarHungry brain=inc. Cortisolinc. hepatic glucagon, inc. muscle breakdowninc. sugar, inc. insulin, inc. fats

Food Improves Mood by Buffering the Stress Response

Reactive hypoglycemiaCarbohydrate cravingsMood swingsShakiness, fainting, etc.

Inc. VAT (sarcopenia)Inc. Blood pressureInc. Blood sugarInc. Triglyerides Inc. InflammationAltered sex hormonesCognitive functionShort term: EnergyLong term: CVD, Metabolic

Syndrome, Obesity, Diabetes, Cancer

Recurring Micronutrient Themes & Stress Hormone Management

• Specific Nutrients

-EPA/DHA

-MVM

-B complex Vitamins B6, B12, Folate

-Magnesium

Omega-3 fatty Acids and Neuropsychiatric Disorders

“…decreased blood levels of omega-3 fatty acids have been associated with several neuropsychiatric conditions, including Attention Deficit (Hyperactivity) disorder, Alzheimer’s Disease, Schizophrenia and Depression…”

Young, G et al: Reprod Nutr Dev. 2005 Jan-Feb:454(1);1-28

Anti-Stress Effects of DHA

• In a double blind two month study, we measured plasma catecholamines and cortisol of students (3 females and 4 males for the DHA group and the same numbers for the control) at the start and end of the study. Students were under continuous stress of final exams that lasted for two months throughout the whole study period.

• The plasma cortisol did not change in either group, but the norepinephrine concentration was significantly decreased in the DHA group (-31%), whereas it stayed at the same level in the control group. These effects of DHA intake may be applied to people under psychological stress.

• Hamazaki T et al. Biofactors 2000; 13(1-4):41-45

Consequences of Magnesium deficiency on the Enhancement of Stress Reactions; Preventive and Therapeutic Implications (A Review)

• Mg deficiency intensifies adverse reactions to stress

• Such reactions are mediated by excess release of catecholamines and corticosteroids

• Low Mg and high Ca levels increase release of stress hormones, which further lower tissue Mg

J Am Coll nutr 1994; 13(5):429-446

MagnesiumMetabolic Syndrome & Inflammation

• Mg intake is inversely associated with systemic inflammation and the prevalence of metabolic syndrome in middle-aged and older women

• Participates in reducing risks to top health challenges facing women: CVD, cancer, stroke, diabetes, obesity

• N=11,686 women > 45 yo participated in Women’s Health Study initially free of cardiovascular disease and cancer and had no use of postmenopausal hormones

Stress Has Many Faces

• Stressed & overworked• Stressed & tired• Stressed & wired• Stressed & inflexible• Stressed & hot• Stressed & cold• Stressed & depleted• Stressed & immune challenged• Disturbed sleep & mood

How Adaptogenic Herbs Buffer Stress Molecules and Protect the Nervous System

• Non-toxic – no change in normal physiology

• Helps the body adapt to stress

• Normalizes body function

Plant Adaptogens

• Balance the way your brain and endocrine system process stress thereby reducing the damaging effects of prolonged exposure to catecholamines and glucocorticoids

• Increase the non-specific resistance of an organism without disturbing normal biological parameters

• Act as a nootropic – a substance that enhances cognition, protects the brain and has low toxicity and few side effects

Disturbed sleep & mood

• 60 million Americans suffer from disturbed sleep, characterized by functional impairments during the day.

• Today, the widespread practice of “burning the candle at both ends” in western industrialized societies has created so much sleep deprivation that what is really abnormal sleep is now almost the norm

Expressions of sleep disturbanceswww.cdc.gov/niosh/stresswk.html

• Difficulty falling asleep• Difficulty waking up in the

morning• Waking up tired• Microsleeps - very brief

episodes of sleep, such as “nodding off”

• “zoning out” in the middle of a conversation or task

• Preferring a late bedtime – 2-3 AM and waking up late, around 10 AM

• Preferring an early bedtime – 8 PM and waking up early, around 5 AM

• Clumsy and/or slower reactions times

• Snoring (sleep apnea)• Routinely falling asleep

within 5 minutes after lying down

• Waking up frequently during the night with difficulty returning to sleep

FDA Warning:Commonly used RX for sleep disorders can disrupt

performance and be addictive

• Valium

• Dalmane

• Ambien

• Restoril

• Halcion

Natural sleep cycle

Light sleep: Body movement decreases. Spontaneous awakening may occur.

Stage 1: dec. serotoninIntermediate sleep: Most of the night is spent in this stage.

Helps refresh the body.Stage 2: dec. MelatoninDeep sleep: Difficult to arouse. Most restorative stage,

lasting 30-40 minutes in first few cycles, less in later cycles.

Stage 3 & 4: dec. SerotoninREM: Dreaming occurs. Heart rate increases. Lasts about

10 minutes in first cycle, 20-30 minutes in later cyclesStage 5: inc.Acetycholine, dec. GABA, dec. Dopamine

REM-NREM Balance

• REM=Ergotrophic• On-line, engaged• Externalized• Hypermetabolic• Cholinergic

• NREM=Restorative• Off line, Autistic• Internalized• Hypometabolic• Serotonergic and

GABAergic

Neurotransmitters Involved in Sleep

• Serotonin-NREM

• Acetylcholine-REM

• GABA-inhibits brain arousal centers, reduces REM

• Histamine-stimulates brain arousal centers, “wake promoting neurotransmitter”

Healthy Sleep Hygiene

• Create a relaxing bedtime routine:Read a bookListen to musicPractice a relaxation techniqueTake a warm bathKeep the temperature in your bedroom at a

comfortable level: extremes can disrupt your sleep

• Go to sleep and wake at the same time each day – helps to develop a sleep-wake rhythm that encourages better sleep

Healthy Sleep Hygiene

No daytime napsGo to bed only when sleepySet a bed routineGet out of bed if you are not sleeping. Get up

after 15 to 20 minutes if unable to fall asleep.Get back into bed only if you are sleepy.Maintain a consistent wake up time, no matter

how much sleep obtained.Use bed for sex and sleep only.

More Ways To Sleep Better

• Watch your diet – a heavy meal or spicy foods before bedtime can lead to nightime discomforts; fluids can require disruptive trips to the bathroom. A light snack can prevent hunger pangs and help you sleep better.

• Eat no closer than 2 hours before bedtime.• Avoid caffeine (tea, cola, chocolate and coffee) and

cigaraette smoking 4 to 6 hours before bedtime.• Have no more than one serving of alcohol consumed 2

hours or more before bedtime.• Exercise regularly – exercising in the morning or

afternoon – at least three hours before bedtime, so you won’t get too revved up – may help you get a deeper, more restful sleep.

Larzelere M. wiseman P. Anxiety, depression, and insomnia. Prim Care Clin Office Pract 2002;29:339-360

Melatonin

• Reduced sleep onset• Increased REM sleep compared to

placebo• Effective in children and adolescents with

ADHD and insomnia• Improves tinnitus• Improvement in behavioral symptoms in

dementia patients• Cluster headaches

Melatonin

• Short half life (approx 1 hour)

• Metabolized by P450 cytochromes

• Physiologic range between 8 to 3 mg

• Modest decrease in sleep latency

• Melatonin has thermoregulatory effects that assist in its sophoric effects, reduces core body temperature

Melatonin: Human Studies

• Analysis of 17 different studies involving 284 pts; melatonin demonstrated reduced sleep onset latency, increased sleep efficiency, and increased total sleep duration (Wurtman et al. Sleep Med Review 2005(9);41-50)

• Two randomized studies demonstrated increased REM sleep percentage (J Clinical Endocrinology 2004; 89:128-134)

• Useful in patients with delayed sleep phase syndrome (Sleep 2005(10);1271-1278)

Melatonin: Safety

• Generally regarded as safe with little risk of toxicity especially in short term use

• Side effects may include fatigue and dizziness• High doses ( 8 mg or above) associated with

reduced sperm motility• Should not be used in pregnancy or breast

feeding• May reduce effectiveness in patients taking

warfarin

Recommended Use of Melatonin

• Administer 30 minutes to 1 hour prior to bedtime

• Dosing varies by age

• Administration of melatonin to older adults results in substantially higher blood levels “less is more”

• Exposure to light will inhibit the sleep promoting effects of melatonin

Passionflower: Overview

• Traditional herb used for its sedative and anxiolytic properties

• Two biologically active flavanoids isolated; Apigenin and Chrysin which bind to benzodiazepine receptors

• Both Apigenin and Chrysin reduce behavioral measures of anxiety in animals in a manner similar to benzodiazepines (Pharmacol Biochem Behav 1994, 47(1):697-706

What is Casein Tryptic Hydrolsate?

• Pure tryptic hydrolysate from milk anxiolytic like profile (on label: “casein hydrolsate”)

• Standardized to 2.2% casein decapetide with molecular mass 1267 Da, corresponds to the peptide 91 to 100 of alphas1 casein by enzymatic hydrolysis using trypsin

• Can be concentrated or isolated by HPLC

Casein Tryptic Hydrolysate

• Demonstrated to be efficacious for stress reduction using conditioned defensive burying test and elevated plus-maze in rats

• Aids sleep• Helps to reduce cortisol• Helps to keep blood pressure levels within the normal

range (modify)• Helps to control symptoms of physiological and

psychological stress• Casein tryptic hydrolysate produces a noticeable effect

in as little as one hour and optimal results can be observed after 10 days of treatment.

Mind-Body & Cognitive Approaches

• Journaling

• Belly breathing

• Relaxation techniques

Stress & Relaxation

• EVERYTHING to do with health

• Worry is the most common effect

• Type II stress is exhausting

• 80% serious illnesses preceded by high stress levels in previous year

• Animal research (Vernon Riley)

Stress & Relaxation

• NOTHING to do with health

• Stress ‘tolerance’ is key

• ‘Stress hardiness’ – Kobasa

• Expand capacity reduce physiologic toll, connect with Inner Resources

• Improve problem-solving abilities

Breath & Back Pain

“Patients suffering from chronic low back pain improved significantly with breath therapy. Changes in standard low back pain measures of pain and disability were comparable to those resulting from high quality, extended physical therapy. Qualitative data suggested improved coping skills and new insight into the effect of stress on the body as a result of breath therapy.”

Mehling WE, et al. RCT of Breath Therapy for Patients with chronic low back pain. Altern Ther Health Med. 2005;11(4)44-52.

ImageryPhysiological Effects

• Heart rate, blood pressure, respiratory rate & rhythm

• Oxygen consumption, CO2 & lactic acid elimination

• Gastrointestinal motility and secretions

• Sexual arousal and function

• Muscle relaxation and function

• Immune system responsiveness

Marketing Opportunities

• Existing patients

• Referrals

• Events/local presentations

• Media outreach

• Corporate wellness

JAMA 2005:294;2010-2011

“…what we do agree on is reduction of risk factors for heart disease and diabetes through lifestyle changes first, is an appropriate treatment.”

Comparison

Our Program AHA Step 1 Diet

Triglycerides -95 mg/dl -49 mg/dl

T-chol -43 mg/dl -2.6 mg/dl

LDL-C -28 mg/dl +3.2 mg/dl

HDL-C +2.8 mg/dl -.5 mg/dl

Weight -14.8 lbs -7.8 lbs

The Cost Effectiveness of Lifestyle Modification or Metformin in Preventing Type 2 Diabetes in Adults with Impaired Glucose Tolerance

“The lifestyle intervention, compared with the metformin intervention, provided greater health benefits at lower costs and, from the prospective of a fiscally prudent policymaker, represents the intervention of choice.”

Annals of internal Medicine 2005; 142:323-332

TLC is more effective, less expensive than

Medication

Lifestyle Metformin

Delay in development of diabetes

11 years 3 years

Reduced incidence of disease

20% 8%

Cost (per QALY)

$1,100 $31,000